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Name _______________________________________________________________________ Home Address ________________________________________________________________ City _________________________________ State __________________ Zip____________ Telephone No. (Home) _________________________ Grade Level _______________________ Why do you want to attend Moon and Mars Camp 2010? _______________________________ _____________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Parent/Guardian Name: ___________________________ Phone number _________________ Emergency phone number ________________________ Name of contact ____________________ Name of Family Doctor: _________________________ Phone number: ____________________ Allergies/medications taken: _________________________________________________________ Other medical information: __________________________________________________________ Please call Elizabeth Strong at (304)23-DINOS or e-mail libby@smartcenter.org if you have any questions. Please fill out form completely and mail
to:
Applications are due by July 14th, 2010...
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